Clinical Pharmacy Specialist

📋 Description

• Review coverage for medications under pharmacy and medical benefits across all lines of business as necessary.

• Conduct research and resolve inquiries, problems, or issues promptly.

• Supervise and manage the support services required for pharmacy services across all lines of business.

• Continuously seek improvements in processes and contribute to both corporate and departmental objectives by handling all requests in a timely, professional, and courteous manner.

• Input, review, and make decisions on Medicare Part B requests for J codes, Q codes, and other medical benefit drugs/supplies.

• Monitor the prior authorization system to ensure turnaround times are adhered to and reach out to providers for additional information to facilitate coverage determination reviews.

• Communicate prior authorization criteria, pharmacy benefit coverage, and formulary alternatives to physicians, their office staff, medical management personnel, and/or pharmacists.

• Inform physicians, providers, and members about decisions regarding coverage determination requests.

• Assist in maintaining policies and procedures, including editing and proofreading tasks.

• Provide support for member and provider inquiries related to authorization, benefit questions, and resolution of pharmacy-related member issues.

⛳️ Requirements

• Minimum of three years’ experience in a health plan or PBM handling prior authorization for medications, especially Medicare Part B and Part D.

• Strong attention to detail in gathering complete and accurate information.

• Proficient in inputting data accurately and efficiently.

• Bilingual proficiency in English and Spanish is preferred.

• Fundamental knowledge of medical terminology and current diagnostic and reimbursement coding (J/Q codes, ICD-10, CMS 1500, etc.).

• Proficient in pharmacy computerized systems and software applications, along with MS Office Product Suite.

• Excellent telephone etiquette and capability to manage multiple phone lines.

• Ability to independently identify and troubleshoot problematic issues.

• Capability to adhere to clinical criteria and instructions for approving prior authorization requests.

• Must be able to meet established deadlines.

🏝️ Benefits

• Competitive salary and comprehensive health benefits.

• Opportunities for professional development and career advancement.

• Supportive work environment with a focus on work-life balance.

• Additional perks and benefits to enhance employee satisfaction.